Vascular sheath with puncture site closure apparatus and methods of use

ABSTRACT

Apparatus and methods are provided for use in sealing a vascular puncture site. The invention comprises an introducer sheath with an integrated closure component. The closure component includes an advanceable resilient spring clip with an expanded delivery configuration in which opposing sides do not contact one another, and an unstressed deployed configuration, in which opposing sides close towards one another. The clip is advanced along the sheath until it pierces opposing sides of a vessel wall at a puncture site. The sheath then is withdrawn, thereby causing the clip to resiliently return to its unstressed deployed configuration and draw opposing sides of the puncture together to seal the wound.

This is a continuation application of Ser. No. 09/478,179, filed on Jan.5, 2000.

FIELD OF THE INVENTION

The present invention relates to apparatus and methods for sealing aniatrogenic puncture in a vessel formed in conjunction with a diagnosticor therapeutic treatment. More particularly, the present inventionprovides apparatus comprising an introducer sheath including a puncturesite closure device comprising an expandable clip with elastic memory.

BACKGROUND OF THE INVENTION

Catheterization and interventional procedures, such as angioplasty andstenting, generally are performed by inserting a hollow needle through apatient's skin and muscle tissue into the vascular system. A guide wirethen is passed through the needle lumen into the patient's blood vessel.The needle is removed and an introducer sheath is advanced over theguide wire into the vessel. A catheter typically is passed through thelumen of the introducer sheath and advanced over the guide wire intoposition for a medical procedure. The introducer sheath thereforefacilitates insertion of various devices into the vessel whileminimizing trauma to the vessel wall and minimizing blood loss during aprocedure.

Upon completion of the medical procedure, the catheter and introducersheath are removed, leaving a puncture site in the vessel. Commonly,external pressure is applied until clotting and wound sealing occurs.However, this procedure is time consuming and expensive, requiring asmuch as an hour of a physician's or nurse's time, is uncomfortable forthe patient, and requires that the patient be immobilized in theoperating room, cathlab, or holding area. Furthermore, a risk ofhematoma exists from bleeding prior to hemostasis.

Various apparatus have been developed for percutaneously sealing avascular puncture by occluding or suturing the puncture site. Forexample, U.S. Pat. Nos. 5,192,302 and 5,222,974 to Kensey et al.,describe the use of a biodegradable plug delivered through theintroducer sheath into the puncture site. When deployed, the plug sealsthe vessel and provides hemostasis. Such devices have been slow to gainacceptance in the medical community, however, due to difficultiesencountered in positioning the plug within the vessel. Moreover, theagents used to occlude the puncture site are animal-derived, typicallycollagen-based. Thus, a risk of adverse immunoresponse exists.

Another previously known technique comprises percutaneously suturing thepuncture site with specialized apparatus. Such apparatus is described,for example, in U.S. Pat. No. 5,304,184 to Hathaway et al. Whilepercutaneous suturing devices may be effective, a significant degree ofskill may be required on the part of the practitioner. Because suchdevices are mechanically complex, they tend to be relatively expensiveto manufacture.

Surgical staples and resilient clips for external skin wound closure arewell known in the art, Examples include U.S. Pat. No. 5,026,390 to Brownand U.S. Pat. No. 5,683,405 to Yacoubian et al, which both describeresiliently deformable closure devices suitable for manual externalapplication.

To reduce the cost and complexity of percutaneous puncture closuredevices, such devices employing resilient clips or staples have beendeveloped. U.S. Pat. No. 5,478,354 to Tovey et al. describes the use ofresilient clips in conjunction with a trocar to close abdominal puncturewounds. U.S. Pat. No. 5,810,846 to Virnich et al. describes aspecialized apparatus for closing a vascular puncture site with aplastically deformable clip. The apparatus preferably is advanced over aguide wire through a cannula to the surface of the puncture site, wherethe staple-like clips are delivered to close the wound.

U.S. Pat. No. 5,782,861 to Cragg et al. describes specialized apparatusfor closing a puncture site with a detachable clip. The apparatuscomprises a hollow shaft, having a distal end formed with one or moreopposed pairs of resilient grasping prongs, that is advanced over aguide wire through a coaxial hollow tube to a position at the distal endof the tube just proximal of the puncture.

The grasping prongs are extended beyond the distal end of the tube tograsp the vessel on opposing sides of the puncture. The shaft then ispartially retracted, causing the prongs to contract within the tube,thereby sealing the puncture site. Both of the devices described in theforegoing patents have the drawback that a separate device must bedeployed through the introducer sheath to close the puncture site, thusprolonging the procedure. Moreover, both devices require relativelycomplex apparatus and involve time consuming manipulation to achievehemostasis.

In view of the foregoing, it would be desirable to provide apparatus andmethods suitable for vascular puncture closure that overcome thedisadvantages of previously known devices.

It also would be desirable to provide apparatus and methods for vascularpuncture closure that quickly and effectively achieve hemostasis.

It further would be desirable to provide vascular puncture closureapparatus and methods that do not require the introduction of additionalapparatus at the completion of the catheterization procedure to achieveclosure.

It still further would be desirable to provide apparatus and methodssuitable for vascular puncture closure that do not introduceanimal-derived material into the bloodstream.

It would be desirable to provide vascular puncture closure apparatus andmethods that are safe, lower cost, and easy to use.

SUMMARY OF THE INVENTION

In view of the foregoing, it is an object of the present invention toprovide vascular puncture closure apparatus and methods that overcomedisadvantages of previously known devices.

It also is an object of this invention to provide apparatus and methodssuitable for vascular puncture closure that quickly and effectivelyachieve hemostasis.

It is a further object of the present invention to provide apparatus andmethods for vascular puncture closure that do not require theintroduction of additional apparatus at the completion of thecatheterization procedure to achieve closure.

It is another object of this invention to provide vascular punctureclosure apparatus and methods that do not introduce animal-derivedmaterial into the bloodstream.

It is yet another object of the present invention to provide vascularpuncture closure apparatus and methods that are safe, lower cost, andeasy to use.

These and other objects of the present invention are accomplished byproviding a vascular introducer sheath having an integrated woundclosure component. The closure component consists of a resilient springclip disposed on and advanceable over the exterior of the introducersheath in an expanded delivery configuration until opposite sides of theclip pierce a vessel on opposite sides of a puncture site. Theintroducer sheath is then withdrawn, enabling the spring clip tocontract to its unstressed deployed configuration, thereby drawingopposite sides of the puncture together and closing the wound. Meansalso are provided for confirming when the spring clip has engaged thevessel wall, thereby indicating to the surgeon that the clip may bedeployed and the introducer sheath may be withdrawn. Alternativeembodiments of the spring clip also are provided.

Advantageously, the closure component is inexpensively integrated into astandard introducer sheath, thereby eliminating the need for a separateclosure device at the conclusion of a catheterization procedure. Thepresent invention provides a quick, safe, effective and easy-to-usetechnique for wound closure that overcomes drawbacks of previously knowndevices. Methods of using the apparatus of the present invention alsoare provided.

BRIEF DESCRIPTION OF THE DRAWINGS

The above and other objects and advantages of the present invention willbe apparent upon consideration of the following detailed description,taken in conjunction with the accompanying drawings, in which likereference characters refer to like parts throughout, and in which:

FIG. 1 is a side view of a vascular device constructed in accordancewith the present invention;

FIG. 2 is a cross sectional view of the closure component of thevascular device of FIG. 1;

FIGS. 3A-3D are side views of the resilient clip of the presentinvention shown from different angles in an expanded deliveryconfiguration and in an unstressed deployed configuration;

FIGS. 4A and 4B are isometric views of an alternative embodiment of theresilient surgical clip, constructed in accordance with the presentinvention and shown, respectively, in an unstressed deployedconfiguration and in an expanded delivery configuration; and

FIGS. 5A-5F are side-sectional views of a vascular puncture site,illustrating a method of sealing the puncture site with the integratedvascular device of FIG. 1.

DETAILED DESCRIPTION OF THE INVENTION

The integrated vascular introducer sheath with closure component of thepresent invention overcomes disadvantages associated with previouslyknown methods and apparatus for sealing a vascular puncture by providinga quick, simple, safe, lower cost, effective, and easy-to-use solutionto wound closure. Apparatus constructed in accordance with the presentinvention provide vascular introduction and wound closure in a singledevice, eliminating the time and manipulation required to insert aseparate closure device at the completion of a procedure.

Referring to FIG. 1, vascular device 10 comprises introducer sheath 12coupled to hub 14, clip housing 16, and clip actuator 18.

Introducer sheath 12 comprises a material typically used for vascularintroducer sheaths, such as polyethylene or nylon, and includes centrallumen 13 through which other devices may be introduced in thevasculature, for example, to perform a diagnostic or interventionalprocedure such as angiography, angioplasty or stenting.

Hub 14 is mounted to the proximal end of introducer sheath 12 andincludes side port 20, arc-shaped lumens 22, backbleed lumens 24,backbleed tubes 25, and device port 26. Device port 26 communicates withcentral lumen 13 of introducer sheath 12, and has self-sealingelastomeric membrane 27 disposed across it. Self-sealing membrane 27,which may comprise, e.g., latex or a biocompatible synthetic rubber,permits interventional devices to be introducer through device port 25while preventing blood loss through central lumen 13. Side port 20 ofhub 14 is in communication with central lumen 13, and is connected tohemostatic port 34 via biocompatible tubing 36.

Clip housing 16 includes an annular-shaped chamber that holds anelastically deformable clip. In accordance with the principles of thepresent invention, clip housing is slidably disposed on the exterior ofintroducer sheath 12 and is movable from a stowed position, adjacent hub14, to a distal clip deployment position, where the spring clip is urgedinto engagement with tissue surrounding vascular puncture.

Clip actuator 18 comprises plunger 28 and rods 30, which are configuredto slidably pass through arc-shaped lumens 22 of hub 14. The distal endsof rods 30 are mounted in clip housing 16, so that movement of plunger28 causes corresponding proximal or distal movement of clip housing 16.As described in detail hereinafter, when plunger 28 is moved to itsproximal-most position, clip housing is disposed adjacent to hub 14 andprovides adequate clearance for interventional devices to be inserteddevice port 22 and central lumen 13 into the patient's vasculature. Whenmoved to its distal-most position, plunger 28 causes rods 30 to urgeclip housing 16 distally.

Referring now also to FIG. 2, the closure component of vascular device10 is described in greater detail. Clip housing 16 comprises bore 38that slidably receives introducer sheath 12, bores 40 in which rods 30are mounted, and backbleed indicator ports 42. Backbleed indicator ports42 are coupled to backbleed tubes 25 via lumens 44. Housing 16 furthercomprises threaded bore 46 with male thread 48 and proximal ledge 50,and clip bore 52 with proximal ledge 54. Threaded bore 46 engages femalethread 56 of clip expander 58. Clip expander 58 is slidably disposed onintroducer sheath 12, and together with the portion of clip housing 16surrounding the spring clip 62 forms annular chamber 60.

Spring clip 62 is stored in its expanded delivery configuration inannular chamber 60 so that it slidably passes over clip expander 58until it abuts proximal ledge 54 of clip bore 52. In a deliveryconfiguration of vascular device 10, the length of annular chamber 60,as measured from the distal end of clip expander 58 to proximal ledge54, extends within the distal end of clip housing 16 for a sufficientdistance to cover the length of clip 62. In this manner, clip housing 16prevents snagging spring clip 62 from snagging on tissue duringadvancement of clip housing 16 to its deployed position, as describedhereinbelow.

Rods 30 pass through arc-shaped lumens 22 of hub 14 and mounted in bores40 of clip housing 16. Distal advancement of rods 30 causes clip housing16, expander 58, and spring clip 62 to advance distally a correspondingdistance relative to introducer sheath 12. When plunger 28 is moved toits distal-most position, rods 30 may be rotated within arc-shapedlumens 22 to rotate and advance clip housing 16 relative to clipexpander 58. This motion causes clip housing 16 to advance distallyalong female thread 56 of clip expander 58 until the proximal end of theclip expander contacts proximal ledge 50 of threaded bore 46. Furtherrotation of rods 30 causes proximal ledge 54 to urge a tissue-engagingportion of spring clip 62 distally off of clip expander 58. With cliphousing 16 positioned at a vascular puncture site P, rotation of rods 30causes the tissue-engaging portion, illustratively spikes, to pierce thevessel wall, as seen in dotted profile in FIG. 2.

In alternative embodiments, plunger 28 and rods 30 may be removablycoupled to clip housing 16, to permit unobstructed access to device port26. In this embodiment, rods 30 may include teeth that may be rotated tofixedly engage bores 40 in clip housing 16.

As discussed hereinabove, backbleed indicator ports 42 are coupled totubes 25 via blood lumens 44 that extend through clip housing 16.Backbleed tubes 25 are slidably disposed through backbleed lumens 24 ofhub 14. When the distal end of clip housing 16 is advanced distallyagainst the vessel wall at puncture P, blood enters blood indicatorports 42 and exits tubes 25, providing visual confirmation to thesurgeon that the distal end of clip housing 16 is positioned adjacent tothe vessel wall. Backbleed tubes 25 thus enable the surgeon to determinewhen clip housing 16 has been advanced sufficiently to permit clipdeployment, while reducing the risk that the clip is either deployedshort of the puncture site or extended into the vessel.

Still referring to FIG. 1, in conjunction with clip deployment, abioglue or tissue sealant may be delivered through hemostatic port 34,tubing 36, port 20 and central lumen 13 of introducer sheath 12 tovascular puncture P to further help seal the vessel after deployment ofclip 62. Alternatively, the bioglue or tissue sealant may be deliveredthrough the backbleed path described above.

Referring now to FIGS. 3A-3D, an illustrative spring clip 62 constructedin accordance with the principles of the present invention is describedin greater detail. FIG. 3B is a side view of the clip of FIG. 3A rotated90 degrees, wherein clip 62 is in an expanded delivery configuration.Clip 62 comprises an annular device having upper members 70 joined tolower members 72 by legs 74 to form lumen 80. Outer spikes 76 and innerspikes 78 are connected to lower members 72, and act as elongatedtissue-engaging members. Clip 62 is elastically expanded by advancingintroducer sheath 12 or clip expander 58 through lumen 80.

Upon removal of the introducer sheath, spring clip 62 resilientlyreturns to its unstressed deployed configuration, illustrated in FIGS.3C and 3D, where FIG. 3C corresponds to the view of FIG. 3A and FIG. 3Dcorresponds to the view of FIG. 3B. When removed from the exterior ofintroducer sheath 12, spring clip 62 resumes its deployed shape, inwhich the opposing sides of the clip come together until lower members72 contact one another, and outer spikes 76 cross inner spikes 78. Asdepicted in FIG. 3A, clip 62 also may optionally comprise engagementmeans 77 to securely engage the vessel being closed. Engagement means 77may, for example, comprise barbs or hooks.

Clip 62 is preferably fabricated from a superelastic material, such as anickel-titanium alloy, but may comprise any material with sufficientresilience to elastically expand for delivery over sheath 12 and fitwithin annular chamber 60 of clip housing 16. Clip 62 also may befabricated from a bioabsorbable material or a combination bioabsorbableand elastically expandable material.

FIGS. 4A and 4B illustrate an alternative embodiment of the resilientspring clip of the present invention, wherein clip 90 comprises hoop 92and opposing spikes 94. In FIG. 4A, clip 90 is depicted in theunstressed, deployed configuration, in which opposing spikes 94 contactone another, whereas in FIG. 4B clip 90 is depicted in the expanded,delivery configuration, in which opposing spikes 94 are separated by gap96. Clip 90 is elastically expanded in a manner similar to clip 62 byadvancement over introducer sheath 12, and preferably also is fabricatedfrom the materials described hereinabove.

Referring now to FIGS. 5A-5F, in conjunction with FIGS. 1-3, methods ofusing vascular device 10 are described. In FIG. 5A, introducer sheath 12has been advanced through skin, fat, and muscle tissue T into vessel V,through vascular puncture P, which is formed in accordance withwell-known techniques. With plunger 28 and rods 30 in the proximal-most,fully retracted position, an interventional procedure then is performedby introducing one or more interventional devices, e.g. angioplastyballoons, stent delivery systems, atherectomy devices, etc., throughdevice port 26 and lumen 13 of introducer sheath 12 in accordance withwell-known techniques. Side port 20 may be used to infuse fluids, e.g.,contrast agents or medications, into the vessel through introducersheath 12 during the interventional procedure.

Upon completion of the procedure, vascular device may be advantageouslyused to close vascular puncture P. At this point, clip actuator 18,housing 16, clip expander 58, and clip 62 are disposed in theproximal-most position adjacent to hub 14, as depicted in FIG. 5A.

As illustrated in FIG. 5B, clip actuator 18 then is advanced by urgingplunger 28 in the distal direction, thus causing rods 30 to slidethrough arc-shaped lumens 22 of hub 14 and advance clip housing 16.Continued distal advancement of plunger 28 causes the distal end of cliphousing 16 to abut against the exterior of the vessel, so that backbleed indicator ports 42 of clip housing 16 directly communicate withthe puncture wound. The presence of pressure in the vessel higher thanatmospheric pressure causes blood to pass through indicator ports 42,blood lumens 44, and exit through the proximal ends of tubes 25, thusconfirming that clip housing 16 is positioned at the puncture site andshould not be advanced further.

In FIG. 5C, with clip housing 16 held immobile, clip actuator 18 isrotated clockwise within arc-shaped lumens 22 so that rods 30 rotate andadvance clip housing 16 with respect to clip expander 58 (see FIG. 2).Specifically, ledge 54 of housing 16 contacts the proximal end of clip62 and drives the clip distally so that its tissue-engaging members,spikes 76 and 78, contact and pierce the wall of vessel V at pointsaround the puncture site, as discussed hereinabove with respect to FIG.2.

Once the spikes have pierced the vessel wall, clip actuator 18 isrotated counterclockwise within arc-shaped lumens 22 to retract cliphousing 16, via threaded bore 46, along clip expander 58. Thetissue-engaging members of clip 62 retain the clip within the wall ofvessel V while the housing retracts, as shown in FIG. 5D.

In FIG. 5E, with clip 62 engaged with the vessel wall, clip housing 16and clip expander 58 are withdrawn proximally by proximally withdrawingactuator 18, thereby causing clip 62 to slide off of clip expander 58.In FIG. 5E, spike 78 is embedded in tissue not shown, because thattissue lies within the plane of the cross section.

Vascular device 10 then is withdrawn from the vessel wall. Onceintroducer sheath 12 is removed from lumen 80 of clip 62, the cliprotates relative to the vessel wall, as shown in FIG. 5F, and returns toits unstressed, deployed configuration, thus drawing opposite sides ofpuncture P together to seal the puncture. At this point, a suitablebiocompatible bioglue or tissue sealant optionally may be injected intothe puncture tract, as discussed hereinabove, through device port 26 orside port, to aid in sealing vascular puncture P. Alternatively, thebioglue or tissue sealant may be delivered through the backbleed pathdescribed above.

Although preferred illustrative embodiments of the present invention aredescribed above, it will be evident to one skilled in the art thatvarious changes and modifications may be made without departing from theinvention. For example, with minor modifications, vascular device 10 maybe configured to carry spring clip 90 of FIGS. 4, or any of a variety ofalternative expandable resilient clips. It is intended in the appendedclaims to cover all such changes and modifications that fall within thetrue spirit and scope of the invention.

What is claimed is:
 1. An apparatus for closing a puncture communicatingbetween a patient's skin and a vessel, comprising: a tubular memberhaving proximal and distal regions and an exterior surface; a housingslidably disposed on the exterior surface of the tubular member, thehousing including a portion defining a chamber; and a clip releasablydisposed within the chamber, the clip being expandable from a deployedconfiguration wherein opposing sides of the clip are directed inwardstowards one another, and a delivery configuration, in which the clip isaccepted within the chamber.
 2. The apparatus of claim 1, furthercomprising an actuator for deploying the clip from the chamber intoengagement with tissue surrounding the puncture to close the puncture.3. The apparatus of claim 2, wherein the actuator comprises an elongatedmember coupled to the housing.
 4. The apparatus of claim 2, wherein theactuator is configured for advancing the housing from the proximalregion to the distal region of the tubular member.
 5. The apparatus ofclaim 2, wherein the actuator is detachably coupled to the housing. 6.The apparatus of claim 1, further comprising a backbleed indicator porton the housing for indicating a position of the housing relative to thevessel.
 7. The apparatus of claim 1, further comprising a side port forintroducing fluids into a lumen of the tubular member.
 8. The apparatusof claim 1, wherein the tubular member comprises an introducer sheathcomprising a lumen for advancing therapeutic or diagnostic instrumentstherethrough into the vessel.
 9. The apparatus of claim 1, wherein theclip is biased to the deployed configuration and is resilientlyexpandable to the delivery configuration.
 10. The apparatus of claim 1,wherein the clip comprises a tubular member from which a plurality ofelongated tissue-engaging elements extend.
 11. The apparatus of claim10, further comprising barbs on the tissue-engaging elements.
 12. Theapparatus of claim 10, wherein the tubular member further comprises aplurality of elongated legs having proximal and distal ends, a pluralityof upper members connecting respective proximal ends of the elongatedlegs, and a plurality of lower members interconnecting respectivealternating distal ends of the elongated legs, wherein the plurality oftissue-engaging members project from the plurality of lower members. 13.The apparatus of claim 1, wherein the clip is bioabsorbable.
 14. Theapparatus of claim 1, further comprising an expander having an exteriorsurface, the expander slidably and coaxially disposed on the exteriorsurface of the introducer sheath, the housing coaxially disposed on andcammingly engaged with the expander for expanding the clip when it isdeployed from the chamber.
 15. A method for closing a puncturecommunicating between a patient's skin and a vessel, the methodcomprising: advancing a tubular member through the puncture into thevessel, the tubular member comprising a housing disposed on an exteriorsurface of the tubular member; advancing the housing distally along theexterior surface of the tubular member into the puncture, the housinghaving a clip therein; engaging tissue adjacent the puncture withtissue-engaging elements on the clip; and drawing the tissue-engagingelements towards one another to close the puncture.
 16. The method ofclaim 15, wherein the tubular member comprises an introducer sheath, andwherein the method further comprises introducing one or more devicesthrough the introducer sheath into the blood vessel.
 17. The method ofclaim 16, wherein the one or more devices are selected from the groupconsisting of an angioplasty balloon, an atherectomy device, and a stentdelivery device.
 18. The method of claim 16, further comprisingperforming an interventional procedure within the patient's body usingthe one or more devices introduced through the introducer sheath intothe vessel.
 19. The method of claim 15, wherein the step of drawing thetissue-engaging elements towards one another comprises withdrawing thetubular member from the puncture.
 20. The method of claim 19, whereinthe tissue-engaging elements are biased to resiliently move towards oneanother from a delivery configuration to a deployed configuration whenthe tubular member is withdrawn from the puncture.
 21. The method ofclaim 15, wherein an actuator is used to advance the housing along theexterior surface of the tubular member into the puncture.
 22. The methodof claim 21, wherein the actuator is coupled to the housing beforeadvancing the housing.
 23. The method of claim 22, wherein the tubularmember comprises a hub having a bore, and wherein a portion of theactuator is inserted into the bore of the hub before advancing thehousing.
 24. The method of claim 15, wherein the step of engaging tissuecomprises deploying the clip from the housing.
 25. The method of claim15, wherein the housing comprises an expander for expanding the clip,and wherein the step of engaging tissue comprises advancing the cliprelative to the expander to deploy the clip from the housing.
 26. Themethod of claim 15, further comprising delivering a tissue sealant intothe puncture.
 27. The method of claim 15, wherein the housing comprisesbackbleed indicator ports, and wherein the housing is advanced distallyalong the tubular member until blood from the vessel flows through thebackbleed indicator ports to a proximal region of the tubular member.28. The method of claim 15, wherein the step of engaging tissuecomprises engaging a wall of the vessel with the tissue-engagingelements.
 29. The method of claim 28, wherein the step of engaging awall of the vessel comprises piercing the wall of the vessel with thetissue-engaging elements.
 30. A method for closing a puncturecommunicating between a patient's skin and a vessel, the methodcomprising: advancing a tubular member through the puncture into thevessel, the tubular member comprising a housing disposed on an exteriorsurface of the tubular member, the housing having a clip therein;advancing the housing distally along the exterior surface of the tubularmember into the puncture until tissue-engaging elements on the clipengage tissue adjacent the vessel; and drawing the tissue-engagingelements towards one another to close the puncture.
 31. The method ofclaim 30, wherein the tubular member comprises an introducer sheath, andwherein the method further comprises introducing one or more devicesthrough the introducer sheath into the blood vessel.
 32. The method ofclaim 30, wherein the step of drawing the tissue-engaging elementstowards one another comprises withdrawing the tubular member from thepuncture.
 33. The method of claim 32, wherein the tissue-engagingelements are biased to resiliently move towards one another from adelivery configuration to a deployed configuration when the tubularmember is withdrawn from the puncture.
 34. The method of claim 30,wherein the housing is advanced until the tissue-engaging elementsengage a wall of the vessel.
 35. The method of claim 30, wherein thehousing is advanced until the tissue-engaging elements pierce a wall ofthe vessel.
 36. The method of claim 30, wherein the step of advancingthe housing comprises deploying the clip from the housing.